Walker, Marjorie A NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Maijorie A Walker Female
Date of Death Age If Veteran of U.S. Armed Forces,
3/15/2020 88 War or Dates
i- Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address 14 Hudson Ave
`p Manner of Death �Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
G Lauren Hendershot,FNP BC
Address
3 Irongate Center,Glens Falls,NY 12801
Death Certificate Filed District Number O Register Number i�7
City, Town or Village
®Burial Date Cemetery or Crematory
❑Entombment March 19,2020 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd Queensbury NY
Name of Funeral Firm Making Disposition or to Whom
pr Remains are Shipped, If Other than Above
Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued $1 �� Registrar of Vital Statistics
Ignature)
District Number () Place Its
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ujDate of Disposition -� r, Ag -_-._ lace of Disposition 21 Quarker RD. Queensbury, NY 12804
W (address)
66B Erie 2
(section) (lot number) (grave number)
Op Name of Sexton or Person in Charge of Premises Connie Goedert
Z (please p 'nt)
W Signature Title
42�" Ot-L
(over)
DOH-1555(02/2004)
Public Health Law Sec. 4145(2b) 010376
Receipt
Human remains of. V, % delivered on , 20
h
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
ALKER
NAME Marjorie A. Walker Age: gg
Lot Owner: James A. & Marjorie A Walker
Lot* ERIE 6 6B Grave#2
Case: Concrete
Died: 3/1 5/2 0 2 0 Interred/1 9/2 0 2 0
Funeral Home:
Regan Denny Stafford
Cemetery: Pine View